Cancer Profile in Patan District, Gujarat: A Comprehensive Review Parimal J. Jivarajani*, Prachi K. Shah**, Jayesh B. Solanki***, Himanshu V. Patel***, Vishruti B. Pandya****, Shilin N. Shukla*****, *Associate Professor and Head, ** Bio statistician, ***Statistical Assistant, ****Junior Statistical Assistant, *****Hon. Director and Professor of Medical Oncology Department of Community Oncology and Medical Records, GCRI, Civil Hospital, A'bad. KEY WORDS : 1)Cancer, Incidence Rates, Method of Diagnosis ABSTRACT : Cancer is a disease which shows significant variation with time and across geographical entities. In this paper, we make a start in that direction, with an aim to measure as accurately as possible the incidence of cancer (all types) in Patan district, to compare Crude Incidence Rates, Age Adjusted Incidence Rates, and TruncatedIncidence Rates with different population based cancer registries of Gujarat state. The Gujarat Cancer and Research Institute (GCRI) is the prime source of data on cancer cases, along with other sources which were recorded cancer cases contributed data for this study. Information on cases from these sources was subjected to meticulous verification regarding repetition, place of residence and other potential errors. The estimated number of cancer cases in 2011 was 310 men and 162 women and the Age Adjusted Incidence Rates (AAR) were 61.84 and 28.63 per 100,000 populations in men and women respectively. Oral Cavity, Colon & rectum, Lung, Leukemia, Esophagus, Stomach, Thyroid, Skin & melanoma, Non-Hodgkin Lymphoma were the commonly observed sites in both sexes. Though it was noted that oral cavity and breast cancer that ranked the first in men and women respectively in Patan district. During the year 2011, 96.45% of the cases among males and 95.06% of the cases among females were confirmed microscopically. The rates of Patan district was exceptionally lower than in other registries. To reach sound conclusions about extent and determinants of cancer, immense multi-spectrum efforts are now needed. INTRODUCTION The burden of Cancer is still increasing worldwide despite advances for diagnosis and treatment. Epidemiological studies have shown that many cancers may be avoidable. It is widely held that 80% - 90% of human cancers may be attributable to environmental and lifestyle factors such as [1] tobacco, alcohol and dietary habits. Based on the GLOBOCAN 2008 estimates, about 12.7 million cancer cases and 7.6 million cancer deaths are estimated to have occurred in 2008, of these, 56% of the cases and 64% of the deaths occurred in the economically developing [2] world. Cancer is not uncommon in India, where the number of people living with the disease is estimated to be around 2.5 million, with over 0.8 million new cases and [3] 0.55 million deaths occurring each year. From the population based registries in India covering 28-30 million population from different parts of the country, the age adjusted incidence rates vary from 44 to 122 per 100,000 population in males and 52 to 128 per 100,000 [4,5,6] females. th Patan, the 14 largest district in Gujarat state spreads in an area of 5,742.19 square kilometers includes 7 talukas Patan, Sami, Harij, Chanasma, Sidhpur, Radhanpur and Santalpur. The patan district has a population of 11, 82,709 with 6, 12,100 males and 5, 70,609 females as per the 2001 census. The Male: Female ratio in Patan district was 932 females per 1000 males. The density of population is 206 persons per square kilometers. The objectives of this study are to determine valid estimates of annual incidence rates of cancer cases, to study cancer profile in the male and female population and to observe method of diagnosis of all the cancer cases registered in the patan district in 2011. MATERIALS AND METHODS Cancer Registration system of Patan district covers more than 100 sources. The trained field staff visits various sources of registration in all government hospitals, private hospitals, nursing homes and diagnostic laboratories besides the base Institution (GCRI) and death registration units in defined area and actively pursued and collected information on cancer cases reported. Trained staff fills the core performa by direct interview with patient or relative at time of registration in GCRI everyday. The inclusion criteria for registration of cases is that patients who have lived in the defined areas of Patan district for a minimum period of one year of first diagnosis of cancer. Correspondence Address : Dr. Parimal J. Jivrajani A-301, Ashirwad Residency, Opp. Jalarammandir, Paldi, Ahmedabad-380006 70 GUJARAT MEDICAL JOURNAL / MARCH-2014 Vol. 69 No. 1
Every cancer death not traceable or not matched with registered cases in record files, with same year or with previous years, was labeled as an 'unmatched death' and the date of death was then taken as the date of first diagnosis, and was so registered in the corresponding year's data file as Death Certificate Only (DCO) cases. As per the National Cancer Registry Programme, (ICMR) this study has started work with data collection, data entry, [7] coding and analysis. The sites of all cancers were [8] classified on the basis of ICD-10 for site coding. Third Edition of the International Classification of Disease for [9] Oncology is being used for morphology coding. th Only invasive cancers (5 digit morphology code 3 or 6) were reported. Benign tumors and insitu cancers are not included for analysis. In this study, Crude Incidence Rate (CIR), Age Specific Incidence Rate (ASpR) and Age Adjusted Incidence Rate (AAR) are used for analysis. The CIR is calculated by dividing total number of new cases registered during a year by corresponding population of that year and multiplying the result by 100,000.Age Specific Incidence Rate refers to the rate obtained by dividing the total number of cancer cases by the corresponding estimated population in that age group and multiplying by 100,000. As age increases, the incidence of cancers also increases therefore with an increase in the median age of population the cancer incidence also increases in the community. In order to make rates comparable between two populations or countries, the five year age distribution of the world standard population is taken into account to obtain the age adjusted rates (AAR). The distribution of cancer cases by method of diagnosis for males and females are calculated. Primary histology, Secondary histology, Cytology and Bone marrow examinations are considered as microscopic diagnosis. Other methods describes as X-ray or Imaging and Death Certificate Only (DCO). OBSERVATIONS The number of cancer cases registered in 2011 was 472 with 310 males and 162 females. The Crude Incidence Rate among males and females were 43.90 and 24.92 per 100, 000 populations respectively. The corresponding Age Adjusted Incidence Rates (AAR) was 61.84 and 28.63. The truncated incidence rate among males and females were 128.17 and 63.77 per 100,000 persons respectively. The Male: Female ratio of cancer cases in Patan district was 1.91:1. Oral cavity, Pharynx and lung were the three commonest primary sites of cancer in males with the rates of 15.44, 10.68 and 7.6 per 100,000 population respectively.(figure:1) In females, Cancers of the breast, cervix uteri and oral cavity were the three most common cancers with the rates of 7.26, 3.72 and 2.81 per 100,000 population respectively.(figure:2 ) The Age Specific Incidence Rates ranges between 2.4 (10-14 year age group) to 277.1 (70-74 year age group) per 100,000 population among males and 1.56 (0-4 years age group) to 116.08 (55-59 years age group) per 100,000 population among females. Graphical representation of leading cancers in patan district is shown in figure: 1 and figure: 2. Estimated numbers of cancer cases, Age Specific Incidence Rates, Crude Incidence Rates, Age Adjusted Incidence Rate (AAR) and Truncated Incidence Rate (TR) for cancer sites for males and females are presented in table: 1 and table: 2. The highest crude incidence rate (CIR) per 100,000 population among males was observed in Ahmedabad- Urban (88.2) followed by Ahmedabad- Rural (52.6) and Gandhinagar (52.47). Similarly among females the highest CR was observed in Ahmedabad-Urban (77.2) followed by Ahmedabad Rural (47.5) and Gandhinagar (39.0). Age Adjusted Incidence Rate per 100,000 populations in males ranged from 68.53 in Gandhinagar to 119.2 in Ahmedabad- Urban. Similarly in females, it ranged from 42.1 in Gandhinagar to 89.2 in Ahmedabad- Urban. The truncated rate per 100,000 populations in males ranged from Gandhinagar district (131.3) to Ahmedabad-Urban (205.8). Again the truncated rate per 100,000 populations in females ranged from Gandhinagar district (99.4) to Ahmedabad-Urban (185). Crude Incidence Rate, Age Adjusted Incidence Rate and Truncated Incidence Rates per 100,000 populations in different Population Based Cancer Registries of Gujarat State were presented in table: 4. The distribution of cancer cases by method of diagnosis for males and females are presented in table: 3. A total of 453 (95.97%) cases were microscopically confirmed. The percentage of cases with microscopic verification of cancer diagnosis was slightly more in males compared to females. The numbers of case registered through death certificates only (DCO) are 13 (2.75%) and X-ray or imaging techniques are 5 (1.06%). The distributions of cancers by detailed microscopic diagnosis and gender are presented in Figure: 3. In males 85.95% of cases were diagnosed through primary histology, 4.01% through cytology and 6.03% through bone marrow. Among females 86.36%, 5.19% and 4.55% were diagnosed through primary histology, cytology and bone marrow respectively. The diagnosis through secondary histology was 4.01% and 3.90% for males and females respectively. DISCUSSION The major concern of this study is to calculate cancer incidence rates and to know cancer profile in the male and female population in Patan district. Total 472 cancer cases were reported in Patan district during 2011. The estimated Age Adjusted Incidence Rates of all cancers in Patan were 61.84 and 28.63 per 100,000 populations in 71 GUJARAT MEDICAL JOURNAL / MARCH-2014 Vol. 69 No. 1
Table: 1 Average Annual Age Specific, Crude (CR), Age Adjusted (AAR) and Truncated (35-64 years) Incidence Rate per 100,000 Population, 2011-Males, Patan district. - - - - - - - - - - - 5.91 5.28 - - - 2 0.28 0.45 1.44 Table: 2 Average Annual Age Specific, Crude (CR), Age Adjusted (AAR) and Truncated (35-64 years) Incidence Rate per 100,000 Population, 2011-Females, Patan district. 72 GUJARAT MEDICAL JOURNAL / MARCH-2014 Vol. 69 No. 1
Table: 3 Distributions of Cancers by Method of Diagnosis and Gender. men and women respectively. The age adjusted incidence rates for all sites together in males varied from 68.53 in Gandhinagar (2011) registry to 68.9 in Ahmedabad - Rural (2009) and for 119.2 Ahmedabad - Urban (2009) registry. In females, the age adjusted incidence rates for all sites together varied from 42.1 in Gandhinagar (2011) registry to 52.9 in Ahmedabad - Rural (2009) and for 89.2 Ahmedabad Urban (2009) registry. The leading sites of cancer for each gender were decided on the basis of proportion relative to all sites of cancer. The major leading sites in male were oral cavity, pharynx and lung which constituted 52.26% of the total cancers in male. The major leading sites in female were breast, cervix uteri and oral cavity which constituted 48.15% of the total cancers in female. According to Gandhinagar, population based cancer registry (2011) oral cavity, lung and esophagus were the commonest sites among males while for females breast, cervix uteri and oral cavity were [10] the most common sites of cancer. The population based cancer registry in Ahmedabad Rural (2009) was founded oral cavity, lung and hypopharynx as the leading sites in males and cancer of the breast, cervix, ovary and myeloid leukemia were the leading sites among [11] females. In Ahmedabad Urban (2009), the most common sites were oral cavity, lung and esophagus among males, while breast, cervix, ovary and esophagus [12] were the commonest sites among females. Clearly from the all population based cancer registries in Gujarat state, cancer of the oral cavity and lung are the commonest sites in males where as cancer of the breast and cervix are the commonest sites in females. We could consider some other study estimates in India. Oral cancer is a major problem in the Indian subcontinent where it ranks among [13] the top three types of cancer in the country. Age adjusted rates of oral cancer in India is high, that is, 20 per 100,000 population and accounts for over 30% of all [14] cancers in the country. Lung cancer is ranked as the leading cancer in Bhopal, Chennai, Delhi, Kolkata and [15] Mumbai, besides north-eastern registries. Breast [16] cancer accounts for 5.8% of all cancer in India, it is the most common cancer of urban Indian women, and the [17] second most common in the rural women and the [18] incidence is on the rise. The incidence of cervical cancer per 100,000 Indian women of all ages varied between 30.0 and 44.9. India bears about one fifth of the [19] world's burden of cervical cancer. On the basis of method of diagnosis 95.97% cases were microscopically confirm in this study. Similarly, [10] Gandhinagar shown 99.09%, Ahmedabad Rural [11] recorded 98.68% and Ahmedabad Urban reported [12] 96.75% microscopically confirmed cases. Table: 4 Crude Rate (CR), Age Adjusted (AAR) and Truncated (TR) Incidence Rates per 100,000 population in different PBCRs of Gujarat State. 73 GUJARAT MEDICAL JOURNAL / MARCH-2014 Vol. 69 No. 1
Figure: 1 Male Leading Cancer sites in Patan, 2011. (Age Adjusted Incidence Rates per 100,000 populations) Figure: 2 Female Leading Cancer sites in Patan, 2011. (Age Adjusted Incidence Rates per 100,000 populations) Figure: 3 Distribution of Cancers by detailed microscopic diagnosis and gender in Patan district, 2011. This type of cancer burden and patterns helps in determining clues to the cause of cancer. With the help of this result certain epidemiological studies are required to ensure the quality of data and common exposure to cancer risk factors. Health education to the public for better nutrition, safe sexual practices, attention to personal self examination and genital hygiene and tobacco control will go a long way in decreasing the incidence of malignancies. [20] REFERENCES 1. WHO, The World Health Report, Geneva, 1997 2. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM: Estimates of worldwide burden of cancer in 2008. GLOBOCAN2008. International Agency for Research on Cancer (IARC)2010;127(12): 2893-2917 3. Nandakumar A, Gupta P, Gangadharan P, Visweswara R, Parkin D: Geographic pathology revisited: development of an atlas of cancer in India. International Journal of Cancer 2005; 116(5): 740-754 4. Cancer Registry Abstract, The newsletter of National Cancer Registry Programme, India 2001;8 5. Parkin D. Whelan S. Ferlay J. Raymond L. and Young J: Cancer Incidence in five continents. IARC scientific publications, Lyon, 1997. 6. Population Based Cancer Registry Report 1991-1995, Regional Cancer Centre, Trivandrum, 1999 7. Three year report of the population based cancer registries: 2006-2007-2008. National Cancer Registry Programme (ICMR) Bangalore, India 2010 8. World Health Organization. Manual of the International Classification of Disease. Injuries, causes of death (ICD-10) Vol 1, Geneva: WHO;1992 9. April F, Percy C, Andrew J, Shanmugaratnm K, Lesile S, Parkin D, Whelan S: International Classification of Disease for Oncology rd (ICD-O) 3 edition. Geneva: World Health Organization, 2000 10. Population Based Cancer Registry Gandhinagar District, Annual Report 2011, The Gujarat Cancer and Research Institute, Ahmedabad 2012 11. Rural Cancer RegistryAhmedabad District Annual Report 2009, The Gujarat Cancer and Research Institute, Ahmedabad 2012 12. Population Based Cancer Registry, Ahmedabad Urban Agglomeration Area, Annual Report 2009, The Gujarat Cancer and Research Institute, Ahmedabad 2012 13. Elango J, Gangadharan P, Sumithra S, Kuriakose M: Trends of head and neck cancers in urban and rural India. Asian Pacific Journal of Cancer Prevention2006;7(1):108-112 14. Sankaranarayanan R, Ramdas K, Thomas G, et al. Effectof Screening on Oral Cancer Mortality in Kerala, India: a cluster randomized controlled trial. The Lancet 2005;365(9475): 1927-1933 15. Ganesh B, Sushama S, Monika S, Suvarna P: A case control study of risk factors for Lung cancer in Mumbai, India. Asian Pacific Journal of Cancer Prevention 2001;12:357-362 16. Chandra A: Problems and Prospects of Cancer of the breast in India. J. Indian MedAssoc 1979; 72: 43-45 17. Agarwal G, Ramakant P: Breast Cancer care in India: The current scenario and the challenges for the future. Breast care (Basel) 2008;3(1): 21-27 18. Kuraparthy S, Reddy K, Yadagiri L, Yutla M, Venkata P, Kadainti S. et al. Epidemiology and patterns of care for invasive breast carcinoma at a community hospital in southern India. World J Surg. Oncol 2007;5:56 19. Shanta V: Perspective in cervical cancer prevention in India. Newsletter 2004; 3.Available at http://www.inctr.org/ publications2003-vo3-no3-wo2.shtml 20. Patel KM: what is cancer, causes and prevention? Gujarat Medical Journal I.M.A.G.S.B News Bulletin 2008; 3(7): 17-18 74 GUJARAT MEDICAL JOURNAL / MARCH-2014 Vol. 69 No. 1